Analysis Navigation Plan Orders Given by the Pilot The distance between Weaver Shoal light and the lock entrance is about 9.5miles, including some 5miles in the Wiley-Dondero Canal. The vessel was not slated for lock transit until0600. This meant that the vessel's speed would have to be reduced to some six knots, assuming that the vessels scheduled to transit the lock before the Federal Bergen did not encounter any delay. The reduction in speed was to take place upon passing Weaver Shoal light. The pilot's intention then was to hold the vessel at the Wilson Hill Anchorage on the north side of the channel. An alteration to 080G (082T) would have kept the vessel on the south side of the channel, and a subsequent northerly alteration for Wilson Hill Anchorage could then have been made as/when convenient to avoid upbound traffic. Alternatively, an immediate course alteration to the north, passing the Weaver Shoal light at close range, would place the vessel on the north side of the channel, on a course to enter the Wilson Hill Anchorage directly and clear of upbound traffic. Regardless of whether the pilot ordered a course alteration to 080G (082T) or to 071G (073T), the vessel's course was altered to 071G (073T). The pilot had extensive experience navigating in this area, and had taken this vessel in-bound. He had a good understanding of where he was and how the vessel would respond. When the pilot gave the command to adjust course, he thought he gave the command to alter course from 077(G) to 080(G), and believed he heard the call-back to that effect. This led him to expect that the vessel was turning to 080; in other words, his mental model was that the vessel was turning toward 080. It is at this point that the pilot's mental model diverged from the ensuing situation, and he lost situational awareness, since the vessel was actually turning to 071. The pilot did not ensure that the vessel had turned to 080, because he was talking with Seaway Eisenhower and planning the trip to the next lock. It can be difficult to simultaneously perform two similar tasks, such as listening to a steering call-back while talking and listening to the traffic control station. Furthermore, expectancies can play a big role in the process of communication3. In this instance, if it is accepted that the pilot had given the command of 080(G), he would have expected to hear back the same information. In performing multiple tasks he was less likely to pick up on his own command error. Furthermore, from the pilot's location on the starboard side of the bridge, the limited visual cues available to him were not compelling enough for him to update/change his mental model and realize that the vessel was not at a heading of 080. It could not be determined with certainty what course alteration the pilot ordered. The next course alteration, according to the chart, was 068(T), off light "68." Given the probable mental model of the pilot, it is unlikely that the pilot ordered starboard course alteration to 080(G). In any event, the vessel's course was altered to 071(G). If it is accepted that this alteration was contrary to the pilot's orders, it would suggest that the pilot did not ensure that the course alteration was correctly executed according to his normal practice, as the course alteration to 071(G) had been effected for some four minutes at the time of striking. The pilot was engaged in several tasks and did not take full advantage of the potential for the OOW to assist in the safe navigation of the vessel. Specifically, he did not communicate the details of his revised navigation plan to the OOW. The pilot's work load was such that he did not monitor execution of the helm order to ensure that it had the desired effect, nor did he monitor the vessel's subsequent progress for about three and a half minutes. The pilot relied solely on his own observations and memory for navigation and to keep track of the vessel's progress. This became a weak link in a system prone to single point failure. The pilot made selective/limited use of navigational aids and, by electing to navigate from the starboard side of the bridge, deprived himself of some of the cues essential for maintaining situational awareness; cues that were critical for safe transit. The cumulative effect of workload associated with Seaway communication, planning and assessing the developing navigational situation, and cursory observation of the navigational aids resulted in the pilot's loss of situational awareness. There was a short delay between the time the OOW became aware of the navigational error and the action initiated by the pilot. The Federal Bergenwas not equipped with a Marine Voyage Data Recorder and consequently, it could not be determined whether the pilot ordered a course alteration to 071G (073T), or to 080G (082T).Findings The pilot was engaged in several tasks and did not take full advantage of the potential for the OOW to assist in the safe navigation of the vessel. Specifically, he did not communicate the details of his revised navigation plan to the OOW. The pilot's work load was such that he did not monitor execution of the helm order to ensure that it had the desired effect, nor did he monitor the vessel's subsequent progress for about three and a half minutes. The pilot relied solely on his own observations and memory for navigation and to keep track of the vessel's progress. This became a weak link in a system prone to single point failure. The pilot made selective/limited use of navigational aids and, by electing to navigate from the starboard side of the bridge, deprived himself of some of the cues essential for maintaining situational awareness; cues that were critical for safe transit. The cumulative effect of workload associated with Seaway communication, planning and assessing the developing navigational situation, and cursory observation of the navigational aids resulted in the pilot's loss of situational awareness. There was a short delay between the time the OOW became aware of the navigational error and the action initiated by the pilot. The Federal Bergenwas not equipped with a Marine Voyage Data Recorder and consequently, it could not be determined whether the pilot ordered a course alteration to 071G (073T), or to 080G (082T). The Federal Bergen struck Weaver Shoal light structure"68" following an erroneous course alteration. The pilot, who was engaged in several tasks including Seaway communication, monitored neither the course alteration nor the vessel's progress. Contributing to the occurrence were the following: sound navigational practices were not followed; the pilot did not make optimal use of the navigation equipment and navigation aids; the details of the revised navigation plan was not communicated to the OOW; and the potential for the OOW to assist in the navigation was not optimized.Causes and Contributing Factors The Federal Bergen struck Weaver Shoal light structure"68" following an erroneous course alteration. The pilot, who was engaged in several tasks including Seaway communication, monitored neither the course alteration nor the vessel's progress. Contributing to the occurrence were the following: sound navigational practices were not followed; the pilot did not make optimal use of the navigation equipment and navigation aids; the details of the revised navigation plan was not communicated to the OOW; and the potential for the OOW to assist in the navigation was not optimized. As a result of similar occurrences, the Board has already addressed deficiencies and issued recommendations regarding bridge resource management training and demonstration of relevant skills (M95-09,10,11,12, ReportSM9501) as well as for pilotage authorities to implement a safety management quality assurance system (M99-06, ReportM97W0197). The Board continues to believe that increased emphasis on information exchange, coordination and quality assurance monitoring would reduce deficiencies, improve bridge team management and advance marine safety.Safety Action Taken As a result of similar occurrences, the Board has already addressed deficiencies and issued recommendations regarding bridge resource management training and demonstration of relevant skills (M95-09,10,11,12, ReportSM9501) as well as for pilotage authorities to implement a safety management quality assurance system (M99-06, ReportM97W0197). The Board continues to believe that increased emphasis on information exchange, coordination and quality assurance monitoring would reduce deficiencies, improve bridge team management and advance marine safety.